PLEASE NOTE UPDATE ON 6/8/20 in the Section discussing Gating Criterion 3: ICU Utilization Rates.

Ongoing analysis of Governor Ducey’s COVID-19 pressers:

May 29th: Governor Ducey Continues to Lie About Arizona’s COVID-19 Status

June 4th: Ducey Stays on Course for Re-Opening, Despite COVID-19 Resurgence

June 22nd: Governor Doug Ducey and interim Arizona DHS Director Dr. Cara Christ presented Arizonans with another COVID-19 update on Wednesday 5/20/20. I actually appreciate that Ducey is doing these regularly.

The presser was, unfortunately, full of elisions, misdirections, half-truths, and outright lies, none of which have the media called him on.

The bottom line is that Arizona is still not ready to open according to the very gating criteria Ducey claims are guiding his decisions.

There are at least three false conclusions that Ducey draws from manipulating the data he presents and the White House/CDC criteria:

• that we have a “contracting” rate of COVID-19 infections in Arizona – cases are actually rising, and possibly just now leveling off;
• that our hospital utilization rate is sufficient for a surge in cases – it is not, according to the CDC’s own guidance on the gating criteria;
• and that our testing program is sufficiently “robust” to proceed – at last, or nearly last, in the nation, our testing capacity is not sufficient to track the spread of the disease as we lessen social distancing.

Let’s walk through the presser together:

After the normal political and corporate PR happy talk about returning stronger and smarter, Ducey actually got to the pandemic response at about 14 minutes in.

Ducey continues to insist, misleadingly, that Arizona has met all the White House’s ‘gating criteria’ for re-opening: unfortunately, it’s just not true, as revealed by our own Arizona Blue Meanie, yesterday.

As documented by covidexitstrategy.org, Arizona continues to fall short of the federal gating in at least three areas:

• Arizona does NOT have a rolling 14-day decline in COVID-19 (we actually have an 18% increasing trend);
• Arizona does NOT have sufficient ICU capacity (we only have 18% available when it should be over 20% for 7 days);
• and, perhaps most importantly, Arizona only has 49% of the needed “robust” testing capacity per capita.

Gating Criterion 1:

Declining COVID-19 Symptoms

13:40 in video

Ducey, skilled PR slinger that he is, just hides the ball in the footnotes on this one. Governor Ducey says, “On symptoms, you want to see a downward trajectory… in a 14-day period. This is what Arizona looks like.” As he pops the slide shown below:

The Governor has not really demonstrated that Arizona meets the ‘declining symptoms’ gating criterion. It’s possible that a declining rate of visits correlates with an overall declining presentation of symptoms, but Ducey presents no evidence to that effect.

His slide actually depicts “COVID-19 average visits” (to the hospital, or a doctor, or both; I have to guess since his chart doesn’t say), in order to bolster his claim that Arizona has a declining rate of symptom presentation. Ducey says, “The blue line is COVID-like illness. The gold line is influenza-like illness,” clearly implying that those lines are fairly representative of the presentation of symptoms of COVID-19 seen in the population.

Here’s the problem with that: by presenting ‘average visits’, this graph could dramatically misrepresent the actual presentation of symptoms.

If people get COVID-19 symptoms, what are they told to do? “Call your doctor or the hospital.”

Call. Not visit.

Most people who develop symptoms will be interviewed about their symptoms, and if they are not presenting the most serious symptoms, such as shortness of breath, low oxygenation, or persistent chest pain, they are told to stay home and isolate until the symptoms pass. Those folks may never ‘visit’ anywhere. So Ducey’s data may only capture a small percentage of what Ducey implies it does.

If we had a real contact tracing program up and running in Arizona, we would have a much more accurate picture of the actual rate of symptom presentation in the population, because we would be looking for it and reporting it to a central database. We are currently just waiting for people to call their doctor or call a hospital. The data that Ducey needs to meet this criterion may not even be reliably gathered by the state.

We could certainly let such an “oversight” in supporting evidence slide if it were not for the self-contradictory and deeply misleading nature of his next claim.

Gating Criterion 2:

Declining 14-Day Average in COVID-19 Cases

18:32 in video

Ducey carefully cherry-picks the data to get to the answer he wants, instead of the one obviously suggested by the best data available.

The White House plan allows a choice between two metrics for this criterion. Ducey chooses to use a ‘decline in the percentage of positive tests for COVID-19’, over the far more probative criterion of ‘downward trajectory of documented cases within a 14-day period’. Note well his exaggerated emphasis on the “or” in the presentation.

First, Ducey displays a chart illustrating the number of COVID-19 cases diagnosed in Arizona. This chart clearly shows an increase in the number of cases over time since the beginning of the crisis. Data for the most recent 14-day period are incomplete, so whether this period is the beginning of a downward trend is impossible to say.

As this slide is displayed, Ducey explains, “This is our total COVID-19 cases by day. You see a lot of information and data here (which I’m sure as hell not going to explain, even briefly, because this is so clearly damning to the case I’m making…[MB]). We’ve been having more testing, and ramping up testing with testing ‘blitzes’ the last three weeks and with more testing, you’re going to see more cases. And this information doesn’t give us the information to make a decision on that stage gate.”

It is true that more testing will produce more documented cases (unless the infection rate has dropped dramatically). However, Ducey is claiming, with a straight face, that the actual rising number of diagnosed cases is not the right information to guide public policy through the epidemic. That’s utter nonsense.

Ducey quickly moves on to display the next slide in his bag of PR tricks:

Ducey explains, “THIS information does. The blue represents the amount of testing that has happened in Arizona, and the gold line represents the amount of contraction of COVID-19 to our citizens who have been tested.” (emphasis added)

Ducey’s argument, that we are doing a lot more testing of late, actually applies here: if you are able to do a lot more tests, you will probably have a smaller percentage of them be positive, so long as cases in the overall population are not growing too quickly. But that tells you nothing about the prevalence of the virus in the whole population, nor how many people are actually sick; the actual number of diagnoses is the better guide. Ducey actually showed those data first, and ignored it as irrelevant because it did not support his desired conclusion.

The CDC’s guidance on the gating criteria actually says, in regard to using Ducey’s chosen alternative metric of “downward trajectory of positive tests as a percent of total tests within a 14-day period with stable or increasing test volume,” that “[i]n circumstances where testing is adequate and testing practices are largely stable, percent positive may be a reliable indicator of COVID-19 activity.” (emphases added)

So, the use of this metric when testing practices are anything but “largely stable”, and the number of cases is actually known to be rising over the past 14 days is contraindicated by the CDC’s guidance on this gating criterion, and strains common sense.

According to the CDC guidance, if you were doing the same number of tests, or maybe a bit more, it could mean there is a declining number of cases in your jurisdiction. But, if you are doing many, many more tests (from 10K a day to almost 40K per day), and you KNOW FOR A FACT that you have a growing number of cases (as Ducey does from his own prior graph), then any decline in positive tests is almost certainly an artifact of your rapidly expanding test capacity.

Ducey’s choice of the less reliable and direct metric is guileful and contrary to the CDC’s explicit advice and mere logic. He’s decision is clearly politically motivated, not scientifically driven.

Ducey just keeps using the word “contraction” in this part of his presentation, as if it means anything as to the data he’s showing. This is just a cheap rhetorical device. There is nothing “contracting” about the epidemic in Arizona at this point.

Ducey is claiming that the declining percentage of positive tests means something other than what the ACTUAL data on case diagnoses indicates: that COVID-19 is in some undefined way “contracting” in Arizona even as the number of infections has grown over the past weeks. That’s just sophistry, not science.

The only conclusion one can draw from this performance is that Ducey is ignoring the data he doesn’t like to spin a tale from the only data he can find that support his favored conclusion–that we meet this gating criterion to re-open–when, in fact, we do not.

Arizona has a rising 14-day average which does not meet the criterion of a falling number of infections over a 14-day period. Ducey is not following the science, he’s following the politics. Arizona is not ready to open by this criterion.

Gating Criterion 3:

ICU Utilization Rate

17:33 in video

UPDATE 6/8/20: It seems that AZDCS had a data reporting issue that resulted in the reporting of an extra 650 filled ICU beds and ~2200 filled regular Inpatient beds. This error by AZDHS changes slightly the past and current utilization rate calculation. The error has been retroactively amended on the DHS COVID-19 dashboard, on which I had relied, and it now seems that Arizona’s utilization rate has been slightly under 80% and briefly over 80% over the past weeks. This section’s discussion was therefore based on incorrect data provided by AZDHS. The underlying concern about hospital capacity remains valid, it is just slightly less dire than the data at the time indicated. MB

This gating criterion set by the White House, and guided by the CDC’s detailed guidance, indicates that a state should have no greater than 80% utilization rate of its total ICU capacity for 7 consecutive days. One wants to have enough critical care beds to get the hospitals through any surge in cases due to re-opening.

Ducey’s chart appears to place Arizona’s utilization at about 75% of capacity, though it is hard to tell exactly due to the design of the chart.

Contradicting his own chart, then Ducey actually admits, “We’ve hovered at about 20% or below over the last several weeks.” He then just claims we have the capacity, but the CDC’s guidance, and his own AZ DHS, say otherwise.

The Arizona DHS COVID-19 Dashboard actually shows that the current percentage of ICU utilization is 83%, and that it has been at or above 80% since 5/13. So, according to the DHS’s own data, Arizona simply does not meet this gating criterion.

Arizona does not meet the ICU utilization criterion, and should not be opening with so little reserve ICU capacity. This could lead to tragic outcomes for some Arizonans with serious illnesses (COVID-19 or not).

Gating Criterion 4:

Testing Capacity

18:20 in video

Ducey doesn’t even try to argue that Arizona’s testing capacity meets the White House criteria, he just assumes it. He says how many tests have been conducted in Arizona, and just totally skips any comparison to any gating criterion. He just gives some raw numbers and doesn’t compare the total to anything else:

There is a good reason for this omission: The CDC and the White House don’t really give any usable metrics; they only say a “robust” testing program for “at-risk healthcare workers” as if that were enough to track and contain any outbreaks.

According to the Arizona Republic: “Arizona ranked 50th out of 50 states, Washington, D.C., and Puerto Rico for its number of tests completed for 1,000 people, according to Kaiser Family Foundation data as of Friday (5/15 [MB]). Arizona has completed 18.5 tests per 1,000 residents, while the national average is 31.5 tests.” I have seen similar comparisons elsewhere and Arizona is invariably in the bottom five.

COVIDexitstrategy.org judges testing capacity by the Rockefeller Foundation National Testing Action Plan (which seems a reasonably conservative place from which to start), which says the U.S. needs to initially get to 3 million tests per week and then 30 million tests per week thereafter. COVIDexitstrategy.org tracks the country’s daily progress towards two goals: reaching 500 thousand tests per day and reaching 4 million tests per week; then the targets for each state are adjusted per capita.

By this criterion, Arizona is at less than half the needed capacity.

By no reasonable criteria does Arizona have sufficient testing capacity, let alone “robust” If Arizona meets this criterion, then EVERY state must, since they all have more testing capacity. A test that everyone automatically passes is not really a test. The White House is merely trying to provide flexibility, not a metric by which to judge any state’s testing capacity with this criterion.

Arizona does not meet any reasonable definition of having a “robust testing program” and should not be re-opening until its testing program is considerably more “robust” than LAST in the nation.

Conclusion:

Again and again, Ducey lies, misdirects, and elides the truth. Arizona IS NOT ready. Arizona DOES NOT meet the White House’s criteria. Arizona’s citizens will pay the price for Ducey’s politically motivated move to re-open the state before its public health capacity and infection metrics demonstrate that it is ready.

This analysis of Ducey’s policy statements doesn’t even include Arizona’s lack of contact tracing capacity and isolation facilities, which I have discussed at length previously, both of which are utterly inadequate to contain the resurgence of infections we can expect by lessening social distancing and re-opening businesses.

Ducey really needs to take a clear-eyed objective look at his own administration’s data, the detailed guidance from the CDC on the White House’s criteria, and the institutional capacity of our public health system to actually diagnose, trace, and treat the anticipated resurgence of the disease before re-opening Arizona. Instead, he’s recklessly throwing open the doors today.

Ducey needs to be honest with Arizonans, and follow the science, NOT the crazy Right Wing political faction of his party pressuring him to re-open immediately. He will find we have a lot of work to do before it is actually safe for our citizens to try to get back to normal.

I want Arizona, and the rest of the country, to return to some kind of normal; but no matter how much we might wish it otherwise, the new normal will be a different normal.

We have to adjust to the virus because the virus will not adjust to us. We can have a vibrant economy and society again, but we will have to take real steps forward and make real policies to prevent, detect, isolate, and treat infections. The new reality can’t be wished, or lied, away. That is the very mistake that China made at the very outset of this pandemic. It will not serve us to repeat it.